Open Jo urnal of Obstetr ics and Gynecology, 2011, 1, 124-127 OJOG
doi:10.4236 /ojog.2011.13022 Published Online Sept e mb er 2011 ( al/ojog/).
Published Online September 2011 in SciRes.
An unusual case of ovarian torsi on w ith infarction simulating
malignancy in an adolescent girl
Madhu Jain1*, Kusum Lata1, Shivi Jain2
1Department of Obstetr ics & Gynecology, In s titute o f Medical Sciences, B anaras Hindu University, Varanasi, I ndia;
2Department of Obstetr ics & Gynecology and Radiology, Inst itute of Medical Sciences, Banaras Hindu University, Varanasi, Indi a
E-mai l : *
Received 11 June 2011; revised 20 August 2011; accepted 27 August 2011.
Torsion of the ovary is an uncommon condition. It is
the 5th most common gynaecological emergency. It
most commonly occur in reproductive age group, on
right side, often in presence of congenital abnormali-
ties of adnexa but may occur in their absence too.
Adnexal torsion often poses a diagnostic challenge
because of non specific symptoms of presentation.
Ultrasound with colour Doppler ma y be helpful.
Keywords: Adenexal Torsion; Ovarian Infarction;
Colour Doppler
Torsion of uterine adnexa is an uncommon condition.
Torsion of ovary is still uncommon. Despite of being
uncommon this is the 5th most common gynaecological
emergency [1], representing 3% of the emergency gy-
naecological surgeries [2]. Adnexal torsion is a diagno-
stic dilemma largel y because of the non specific clinical,
laboratory, and imaging findi ngs [3].
A 15 year old unmarried girl Miss M.R., presented in our
out patient department with the complains of dull ac hing
pain in lower abdomen for one year. It was more on right
side, episodic, non radiating, not responding to medica-
tions. The pain was increased in severity for last five to
six days. It was consta nt, radiating to suprap ub ic region,
with some relief on medication not associated with nau-
sea or vomiting. For this ultrasound was done in a pri-
vate hospital and told of having some tumour. She de-
nied o f ha ving an y ga s tr oi nte s t ina l o r genito uri na r y s ym-
ptoms. She achieved menarche one year back. Her
cycles were irregular at 2 - 3 mo nths, o f 8 - 10 days du-
ration with average flow. Her last menstrual period was
seven days back.
On examination she was alert, oriented and in severe
agony due to the pain. Her temperature was normal, re-
spiratory rate was 16 breaths/min, heart rate was 88
beats/min, and blood pressure was 110/70 mm Hg. Her
secondary sexual characters were normally developed.
Her cardiovascular and respiratory examinations were
unremarkable. Abdominal examination revealed a firm
lump in the lower abdomen of approximately 24 weeks
size involving iliac fosae, both lumbar, umbilical and
hypogastric areas. It was immobile, tender, overlying
skin was normal looking, lower ma rgins wer e not re ached.
She had no hepatosplenomegaly and bowel sounds were
normal. In per rectal examination, rectal mucosa was
free and fullness was felt anteriorly.
A pelvic ultrasound with colour Doppler was per-
formed, showing a large heterogeneous well defined
elongated pelvic mass of 17.3 × 11.1 × 9 cm, arising
from right adnexa with multiple cystic areas and right
sided subhepatic extension, suggestive of ovarian mass
(Fi gure 1). T here wa s no signific ant colour Do ppler flow.
Both ovaries were not visualized separately. How- ever
CECT pelvis revealed heterodense solid cystic mass
lesion in pelvis arising from right adnexal region with
mild pelvic ascites and mesenteric fat stranding, en-
larged pelvic lymph node, suggestive of malignant right
ovarian mass (Figure 2(a), 2(b)). MRI also reported a
well de fine d pre domina ntly c ystic ma ss a nd an eccentric
solid component, with an extension and encasement of
right distal commo n iliac, proximal exter nal iliac and in-
filtration of neurovascular bundle, suggestive of Germ
cell tumour with possibility of malignant degeneration
(Figure 3(a), 3(b)). Patient was also evaluated with
tumour markers such as LDH,
-HCG, Ca-125 & α-
fetoprotein, out of which only LDH was mildly in-
creased. Laparotomy was done after proper evaluation. A
large blackish right ovarian mass of approximately 25 ×
15 cm was present (Fi g u re 4). On delivering the ovary
out, 4 - 5 twist was present around ovarian ligament.
Histo patholo gy turne d out to , the ri ght ovar ian hae morr-
hagic cyst.
M. Jain et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 124-127
C opyright © 2011 SciRes. OJ OG
Figure 1. A large hetero geneous well defined mass with multiple cystic areas in USG.
Figure 2. CECT Pelvis. (a) Axial plane shows a well defined heterodense solid cystic mass lesion (17.2 × 8.4 cm) arising from
right adnexal region and encasing right distal common iliac artery. (b) Coronal plane shows extension of right adnexal mass
into hypogastrium, right iliac foss a, lumbar and epigastrium causing displacement of surrounding bowel loops.
Ovarian torsion first described by Kuestner in 18911,
results from partial or complete rotation of the ovarian
pedicle on its long axis, potentially compromising ve-
nous and lymphatic drainage. If the rotation is partial or
intermittent, the venous and lymphatic congestion may
subside quickly, along with symptoms. If rotation is
complete and prolonged, venous and arterial thrombosis
occur, ultimately causing infa rction. Volume of the twisted
ovary averages 28 times the normal size. The ovarian str-
oma may be heterogeneous due to haemor-rhage and
oedema. Torsion is rarely bilateral and is more common
on the right side, perhaps because the sigmoid colon
leaves limited space for left adnexal mobility. Torsion
occurs mo re co mmonl y in yo ung wo men, with the great-
est incidence in the 20 to 30 year age group [1].
M. Jain et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 124-127
Copyright © 2011 Sc iRes. OJ OG
Figure 3. MRI Pelvis of the same patient. (a) Coronal plane in T2W sequence shows a well defined right ad-
nexal mass with an eccent ric solid mural nodul e. (b) Sagittal plane in T2W sequence shows superior extension
of the mass into lower abdominal cavity with an eccentric solid component in the posterior wall.
Figure 4. A large, blackish, infarct ed right ovarian mass.
Torsion of a normal ovary is unusual but is more
common in adolescents in whom developmental abnor-
malities are there such as markedly mobile fallopian
tubes, absent mesosalpinx, elongated pelvic ligaments.
Fallopian tube spasm, strenuous exercise or abrupt
changes in intraabdominal pressure can also cause tor-
sion o f normal ovarie s. These factors might be responsi-
ble fo r tor sion in o ur p atient i n the ab sence of co ngenita l
abnormality. The varied imaging features and nonspe-
cific symptoms of ovarian torsion can lead to a delay in
identification with misdiagnosis being common [4].
Ovarian torsion is a surgical emergency that often pre-
sents a difficult diagnostic challenge. A detailed history
and p hysica l exami natio n incl uding a pelvic exami natio n
is necessary. Ancillary tests such as tumour markers are
useful to exclude the possibilities of malignancy. Ultra-
M. Jain et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 124-127
C opyright © 2011 SciRes. OJ OG
sound with or without colour Doppler imaging may be
[1] Hibbard, L.T. (1985) Adnexal torsion. American Journal
of Obstetrics and Gynecology, 152, 456-461.
[2] Chris, M. and K i ek, M. (2006) Ovarian torsion in a 20
year old patient. Canadian Journal of E merg ency Med-
icine, 8, 126-129.
[3] Mark, A.H. and Terry, M.S. (1989) Ovarian torsion:
Sonographic evaluation. Journal of Clinical Ultrasound,
17, 327-332.
[4] Han nah, C.C., et al. (2008) Pearls and pitfalls in diag-
nosis of ovarian torsion. Radiographics, 28, 1355-1368.